The Death Shift

by Peter Elkind

  Many who worked in the pediatric ICU at Bexar County Hospital were asking the same question. Around cafeteria tables and in hallways, a growing number of people who suspected something was terribly wrong began calling Genene’s hours on duty the Death Shift.

  Pat Belko, of course, had heard the ugly whispers about Genene. She considered it vicious gossip. Belko knew that the nurses who were talking the most didn’t like the LVN. Besides, their scenario was unthinkable: Nurses didn’t kill babies. The notion was particularly discordant with Belko’s high opinion of Genene. She seemed to care so much for the children and get along so well with their families; it just didn’t fit that she would do anything to harm them. Sure, Genene was abrasive. She was even a bit odd; Pat had seen her hold a child’s corpse up to a window, as if offering the body to the heavens. But Pat continued to regard Genene as an outstanding nurse. When she completed the LVN’s annual performance evaluation—on September 15, when suspicions were already widespread—Pat gave her uniformly high marks. “Ms. Jones has continued to provide excellent patient care and support to families,” the head nurse reported. “Her assistance in orienting new employees has been invaluable.”

  Pat Belko’s defense of her nurse went far beyond passive skepticism. She became angry. She believed the other nurses were smearing Genene’s reputation, persecuting her without cause. She knew Genene’s accusers had no proof. Belko told them to document their suspicions or shut up. She threatened to discipline anyone who kept talking about Genene’s harming children. The vehemence of Belko’s sentiments surprised her subordinates, who had never known Pat as a woman of strong opinions. But they were unaware that their boss had personal cause to sympathize with a nurse under suspicion of killing a baby.

  Her reason dated back a decade, to December of 1971, Pat’s first year on the night shift in the pediatric ICU. One of the unit’s patients was a sixteen-month-old baby with Down’s syndrome, a collection of severe birth defects. San Juanita Ybarra came from Hondo, a hamlet thirty miles west of San Antonio. She had arrived at the hospital suffering from pneumonia and heart failure. She died at 7 A.M. on Sunday, December 5.

  The physician on duty in the ICU wrote in the child’s medical chart that the baby had been killed by an accidental overdose of digoxin, a powerful drug that slows the heartbeat, administered six hours earlier. A nurse had given the child .45 milligrams of the drug, ten times the amount on the doctor’s written order. Hospital administrators summoned police, and the episode soon made the papers. The RN, who admitted misreading the order, was suspended pending investigation.

  An impartial doctor’s inquiry, completed a few days later, proved inconclusive. The physician attributed the baby’s death to pneumonia, while adding that the overdose “may have contributed.” Whatever the actual impact of the error, there was never any suggestion that it was anything but an honest mistake—the sort to which no nurse or doctor is immune. The RN was reinstated and went on to become head nurse in the pediatric ICU. But Pat Belko long remembered the horror of being blamed for the death of a helpless child.

  Suzanna Maldonado had heard the head nurse’s demands for evidence and set about meeting her challenge. A twenty-five-year-old RN, Maldonado had worked for two years on the ICU’s night shift, where suspicions of Genene were high. In her early months at the hospital, Suzanna was friendly with the LVN; they had gone on a river outing together, and Maldonado had cared for Genene’s daughter, Crystal, who had been hospitalized briefly for an accidental overdose of Tylenol. But soon the relationship turned to one of bitter rivalry. A slender, dark-haired woman, Suzanna had grown up on San Antonio’s West Side, the sheltered and dutiful daughter of working-class Hispanics. Still unmarried, she lived with her mother. Genene considered Maldonado a spoiled child—and thought herself a better nurse. Suzanna regarded Jones as an overaggressive LVN who failed to recognize her limitations.

  When children started dying in unlikely numbers on the 3–11 shift, Maldonado was quick to wonder. If the kids were truly that sick, why did they always die on Genene? Why didn’t they die on someone else? Suzanna began making a point of caring for Genene’s patients when she came on duty at 11 P.M. She reviewed Jones’s nursing notes. She began studying the ICU’s patient register, the record of what had happened to children treated in the unit. She even compiled a death list—a diary of all the children who had died since January 1981, showing the time each had expired.

  One morning in October, after finishing up the overnight nursing shift, Suzanna Maldonado stepped into the office of her boss. Pat Belko could not have been pleased to see her—Suzanna was not one of her favorites—and she was even less pleased when she found out what Maldonado had on her mind. Nervous but determined, Suzanna bluntly stated the suspicions that the nurses had long discussed among themselves. Belko jumped to scold; accusations like that shouldn’t be made lightly. But Maldonado wasn’t through. She explained that she had researched the records of patient deaths, that she knew just how many children had died on Genene’s shift. “It looks bad,” she told Belko.

  Belko was shaken by what she heard. For the first time, one of the nurses had presented the sort of information it was impossible for her to ignore. After sending Maldonado from her office, the head nurse walked the length of the fifth-floor corridor to the pediatric ICU. She went to the nursing station, pulled out the unit’s patient register, and flipped through it. Maldonado had done her homework; her numbers were correct. Dr. Robotham was in the ICU, finishing up his seven-thirty rounds. Belko asked to speak with him, and the two of them walked back to her office. She told Robotham what she had learned, and they agreed: There would have to be an investigation.

  Eight

  Jose Antonio Flores, six months and three days old, met a horrible end on the afternoon of October 10. His final code seemed to last an eternity. Unable to understand why Jose was dying, doctors tried for almost an hour to save him, as blood puddled beneath his body. The baby had entered Bexar County Hospital only four days earlier, suffering from a common set of pediatric problems: fever, vomiting, diarrhea, and dehydration. When he developed seizures during his third day on the pediatric ward, he was taken to the hospital basement for a brain scan, in the company of Genene Jones. He went into cardiac arrest while he was there. Doctors revived the baby and rushed him back to the pediatric ICU, where they noticed he was bleeding. Blood samples sent for tests showed Jose’s clotting mechanism wasn’t working. The problem cleared overnight. The next day, the child experienced more seizures and bleeding, before his heart stopped once again. He died at 5:22 P.M. On Jose Flores’s death certificate, a resident blamed the bleeding for his fatal cardiac arrest. The doctor noted that the cause of the bleeding was unknown.

  The events following the baby’s demise were as peculiar as those that produced it. When a doctor informed Jose’s family that he had died, the infant’s father clutched his chest in pain. Genene led the stricken man, accompanied by a half-dozen relatives, to the emergency room—and permitted the baby’s brother to carry Jose’s corpse along too. Assigned to take the body to the morgue, Genene suddenly decided outside the ER to reclaim her dead patient. Without warning, she snatched the bundle from Jose’s brother, gathered the body in her arms, and took off down a hospital corridor, with the child’s relatives close behind. The bizarre chase ended when Genene lost her pursuers in the bowels of the hospital and made her way to the morgue.

  There was never any question that it was Dr. Robotham who would investigate. Bexar County Hospital’s nursing department certainly had no interest. After dutifully reporting Maldonado’s suspicions to the medical director, Pat Belko told her boss, Judy Harris, the hospital’s nursing supervisor over the area including pediatrics. The two women agreed there was nothing to worry about. The unit just seemed to be getting sicker children. Genene cared for the worst of them; it was natural that they would die in greater numbers under her care. Harris then took the problem to her boss: Virginia Mousseau, the hospital’s assistant executive direc
tor and its top nursing administrator.

  Mousseau, fifty-five, was a native of Minnesota with a degree in nursing administration. After being hired in 1979, she began convening monthly nursing management meetings, where there was much earnest talk about developing leadership skills and setting goals. Among her innovations was a requirement for new nurses to wear a tag reading: “I’m new here, please help me to learn.” Mousseau was in the habit of establishing ad hoc committees to deal with problems. Said a former hospital supervisor: “Virginia could spot more problems and solve fewer than anybody I met in my life.” After hearing of accusations that a nurse was killing children, Mousseau advised Harris and Belko to make sure that hospital procedures were being followed. She ordered no other action.

  Jim Robotham similarly had taken the matter to his boss: Dr. Robert Franks, the acting chairman of the pediatrics department at UT. Franks had inherited the job in July, after conflicts with the faculty prompted the previous chairman to step down. At forty-seven, he was the classic caretaker. A veteran of thirteen years at the medical school, Bob Franks was well liked by his colleagues and had no desire to keep the chair himself. Born in Fort Worth, he spoke slowly and softly. His field of pediatric endocrinology—the study of glands and their secretions—possessed none of the drama of intensive care.

  When Robotham brought the suspicions about the ICU to his attention, Franks was naturally skeptical. But Robotham wanted to investigate. The medical director had long shared Pat Belko’s high regard for Genene Jones as a nurse. But he had sensed for several months that something was wrong in the ICU. He had grown concerned about Genene’s personal behavior and the conflicts among the staff. And he was puzzled by some of the deaths. For a while, Robotham had figured that mistakes by some of his residents and the spotty nursing staff were to blame. But there were problems that mere sloppiness couldn’t explain. After Maldonado complained to Belko, Robotham became determined to find out what was going on. Franks told him to go ahead.

  From the beginning, Dr. Robotham worried about heparin. Several children, like Jose Flores, had developed bleeding problems in the ICU. Blood would leak from old needle punctures, ooze out of suture sites, their mouths, even their rectums, until finally their blood pressure would drop, straining their hearts until they stopped. Doctors had been diagnosing the bleeding as symptomatic of disseminated intravascular coagulation (DIC), a relatively rare condition often caused by severe infection, which can set off a reaction that keeps blood from clotting. But there seemed to be too many cases. The problem had never cropped up with such frequency before.

  There was one other possibility: heparin, an anticoagulant drug that doctors and nurses used every hour in the ICU; a small amount kept IV and arterial lines from clotting with blood. Was someone giving the children too much? Or could there be a more innocent—though equally deadly—explanation: Was it possible the drug company had made the heparin too strong? Robotham had other worries. Several children, like Chris Hogeda, had experienced arrhythmia, a sudden quickening or slowing of the heartbeat, which doctors usually see only in adults. Injection of digitalis could explain it. Still other children became lethargic. Robotham wondered about Valium.

  The medical director, of course, was aware of the worst suspicions about Genene. But murder was only one unlikely diagnosis on his list. As a scientist, Robotham intended to examine all the possibilities—to look for the zebras, as he advised his residents. Even a presumption of deliberate misconduct didn’t necessarily point to Genene. The LVN had no shortage of enemies; as crazy as this whole business was, it was entirely plausible, figured Robotham, that someone was setting her up.

  On October 15, Albert Garza, three months old, arrived in the ICU. A victim of Down’s syndrome, Albert had been recuperating from dehydration, diarrhea, and a chemical imbalance called acidosis, when he had an unexplained bleeding episode during the 3–11 P.M. shift. Two residents treating the child—Larry Hooghuis and Wayne Yee—knew there were worries about heparin. When they next took overnight call, on October 17, they alternated sitting by the baby’s bedside for hours, conspicuously standing guard. A skinny, strong-willed Yankee, Hooghuis was one of the residents who got along badly with Genene Jones. He knew it seemed crazy, but his patients seemed to go downhill when his relations with the LVN were at their worst. Midway through the evening, Hooghuis and Yee were called from the ICU to check out a patient on the floor. Albert’s nurse, Genene Jones, summoned them back a few minutes later; the baby’s blood wasn’t clotting.

  Yee quickly drew a sample and mixed two drops with protamine sulfate, a drug that counteracts the effect of heparin. Albert’s blood clotted, suggesting that he had received too much anticoagulant. Hooghuis then noticed that Genene was preparing to clear an arterial line into the child’s body with a diluted solution of heparin. Hooghuis asked her how much heparin she was using. Astonished at her answer, he told the LVN to repeat what she had said. Genene’s concentration was 333 units per cubic centimeter of fluid. The proper dosage was less than one unit; Jones was about to give Albert a massive overdose before their eyes. When the nurse disputed his numbers, Hooghuis grabbed a piece of the baby’s bed sheet and scribbled out his calculation. Genene muttered and stalked off. Albert’s bleeding did not recur.

  The next morning, Robotham told Pat Belko—who explained the episode as an innocent miscalculation—that he wanted heparin handled more carefully. He first reduced the concentration of the anticoagulant to be used in arterial lines. Each nurse was told that she had to have a second nurse watch whenever she drew heparin from its container. Both nurses would have to initial the bottle to show who had conducted and witnessed the procedure. Robotham also began a full-scale effort to separate true DIC cases from possible heparin overdoses. Establishing an overdose of heparin or some other drug would require extensive laboratory tests. Robotham ordered the pediatrics residents to draw and send to the lab extra blood samples whenever a child unexpectedly soured.

  The nurses in the pediatric ICU weren’t told why doctors were suddenly ordering an assortment of unusual lab tests. But after the first couple of times it happened, they realized there was an investigation. Many were upset; Robotham’s measures placed everyone under suspicion. The ICU’s lines of division hardened. Some nurses and doctors believed there was nothing wrong, that J.R. was overreacting, making much ado about nothing. Residents who had experienced no problems with Genene continued to trust her. Some were so friendly that she cut their hair in the ICU’s back room.

  But others openly wondered whether she was trying to preserve life or to end it. One evening, she was caring for a boy who had nearly drowned in a hot tub. When the patient arrested, Genene implored the residents running the code to give up. “Why don’t we let this child die?” she demanded. “He doesn’t have any brain left. Why don’t we let this child die?” The patient’s father asked the doctors to keep the boy on life-sustaining equipment until morning to allow the boy’s mother a little more time to prepare herself for his death. One of the doctors returned to the ICU and carefully explained the family’s request. Suddenly the boy went into seizures and arrested again. “She continued to badger us during the code,” recalled the resident. “She gave the drugs, but she kept on badgering: ‘Why are we doing this? Why are we continuing to support this child?’ It was just the nagging; you wanted to go, ‘Shut up and leave us alone!’”

  More than one resident had caught Genene in a lie. Cheryl Cipriani’s experience came when Jones issued an urgent call for the doctor to return to the bedside of one of her patients. When Cipriani arrived, Genene handed her a filled syringe. “You need to push this,” she declared. The nurse said it was a sugar solution, that she had just tested the baby’s blood sugar and it was dangerously low. The doctor was puzzled. There was no reason for the child to be hypoglycemic. Cipriani ran the simple sugar test herself, and it read normal.

  Even those who were most suspicious handled the LVN gingerly, aware that Genene responded to confrontation by tryi
ng to prove herself right. Dr. Hooghuis’s observation had become accepted wisdom among the residents: Kids did worse in the ICU when their doctors took her on.

  Genene blamed the residents. She complained often that they were slow to arrive when she summoned them. Somebody ought to investigate, somebody from outside, Jones loudly declared. In October, there were eight codes—all of them on Genene’s patients. Posing as the voice of experience, the LVN offered her own explanation for the pattern of arrests. She told the younger nurses that the 3–11 shift had always been the busiest—that children just seemed to pick those hours to die.

  As the ICU grew more chaotic, Genene’s insubordination grew more brazen. When a child arrested in October, Genene directed a new male RN to handle the code. To the charge nurse’s query as to why she was issuing commands, Genene said Pat Belko had ordered the arrangement to give the new RN experience. The charge nurse learned later that Belko had never issued such a directive. On another occasion, Genene clocked out of the ICU an hour early without permission. The charge nurse on her shift was unaware she had even left. “This offense could be grounds for suspension and discharge,” noted Belko, in yet another incident report. But Pat merely issued Jones another “final” warning.

  Even the head nurse, Genene’s benefactor, experienced her insubordination. A day after directing Genene to restock the ICU’s formula cabinet, Pat discovered the task was not done. “I asked why you didn’t do it,” Belko wrote, in her report of the incident. “You stated you hadn’t heard me. At the time I made the request, you and I had been talking to each other face to face.” Even for so personal an act of defiance, even after so much, Belko handled Genene as if it were her first offense. “I am concerned that you decided not to do the task as requested and want you to realize that deliberate failure to follow a supervisor’s orders can be construed as industrial insubordination,” Pat wrote. “You and I have previously discussed the need for an improvement in cooperation.” The head nurse construed kindly; she took no disciplinary action. Genene continued to act with impunity.